Independent investigation: Stuart Robertson, Glasgow (2004)

The Health Board must ensure that there is a systematic approach to risk assessment and management within the forensic psychiatry service. In the Inquiry’s view, the systematic use of formal risk assessment measures may be helpful in this, but they should not be regarded as sufficient. In the present case, there was inadequate clinical risk assessment and monitoring. The Health Board should ensure, therefore, that clinical staff are aware of the need to analyse the relationship between an individual’s mental disorder and the associated risks and that they take a systematic approach to monitoring this.

The Health Board must ensure that written risk assessments and management plans are shared between all members of the clinical team and are easily available in the patient’s case notes. For restricted patients, it should consider sharing them with general practitioners and other primary care staff who may come into contact with the individual. The principles of the Mental Health (Care and Treatment) (Scotland) Act 2003 should be considered in deciding whether to share them with the patient and his or her carers.

The Health Board must review the functions of Community Psychiatric Nurses caring for high-risk patients, especially those subject to restriction orders. It should do this in consultation with the SEHD Mental Health Division.

The Health Board must improve the training of Community Psychiatric Nurses to ensure that they have the required competencies to carry out their functions in relation to conditionally discharged patients. It must also ensure that these nurses are supervised by senior practitioners who take a proactive approach to case scrutiny and discussion.

The Health Board must take immediate steps to improve the clinical governance of the service, in relation to the work of consultant psychiatrists caring for high risk patients in the community. It should review its arrangements for appointing locum consultants and take steps to give them appropriate guidance, support and supervision. It must ensure that there are standards for the handover of information between successive RMOs, and that these standards are audited.

The Health Board must ensure that a restricted patient has a Responsible Medical Officer at all times.

The Health Board must improve the clinical leadership within the forensic service, to ensure that the service has a culture which supports and promotes good standards of clinical care, communication and record keeping.

The Health Board must ensure that there are clear readmission arrangements for conditionally discharged patients and that these arrangements have the support of the consultant psychiatrists involved. It must also ensure that these arrangements are clearly understood by any RMO taking over the care of a conditionally discharged patient.

In the light of the Inquiry’s conclusions about the management of Mr L’s case, The Health Board should audit the RMO’s work in respect of other restricted patients, to ensure that their management is being carried out to a satisfactory standard. In addition, the Inquiry would encourage the Health Board to audit the work of all consultants responsible for the supervision of restricted patients.

The Health Board should consider making the conclusions of this report known to the locum RMO’s present employer, so that it can consider whether to audit his work in respect of restricted patients.

The Social Work Department must review its operational policies and procedures, in respect of its supervision of conditionally discharged patients; it should involve all relevant sections of the Department in the review. It should carry out the review in consultation with the Health Board and the SEHD Mental Health Division.

Social workers supervising conditionally discharged patients must be Mental Health Officers. The Social Work Department must ensure that these social workers have the necessary competencies and training to carry out their supervisory function. In the Inquiry’s view, this includes mental state and risk assessment skills, as well as generic social work skills.

The Social Work Department should ensure that Mental Health Officers supervising conditionally discharged patients have regular supervision, in respect of this work, from a senior member of staff, who has experience of working with high-risk patients. The supervision sessions should be recorded.

The Social Work Department should review the written clinical information that it requires to carry out its supervisory functions and ensure that this is contained within the individual’s case file. In the view of the Inquiry, this should include a formal risk assessment and risk management plan, including a crisis management plan. This documentation should be common to all the health and social care practitioners working with the individual.

The Mental Health Division should identify the competencies that it expects in RMOs caring for restricted patients. It should do this in consultation with Medical Directors of Health Boards and the relevant sections of the Royal College of Psychiatrists. The Division should seek reassurance from Health Boards caring for restricted patients that the relevant RMOs either have these competencies or are being trained to acquire them.

The Division should insist that a formal written risk assessment and risk management plan, including a crisis management plan, is in place, before submitting a recommendation for conditional discharge to the First Minister. It should ensure that the symptoms and signs of the individual’s mental disorder are addressed in such assessment and planning. The Division should insist on regular written reviews of the assessment and plan, following the granting of conditional discharge.

The Director of Service Planning and Policy should ensure that there is a post within his directorate which carries responsibility for strategic leadership of the SEHD’s work with restricted patients. This post should be of sufficient seniority to review objectives, structures, procedures and roles, and to make changes where necessary.

The current Memorandum of Procedure on Restricted Patients should be reviewed in the light of the recommendations of this Inquiry.